Summary On 16 July 2002, in fair weather and good visibility, the loaded bulk carrier Kent was downbound off Verchres, Quebec, under the conduct of a pilot. In the late afternoon, the bosun and another crew member were securing the port lifeboat ready for sea. The bosun was sitting on a davit cradle securing the trigger line when the lifeboat suddenly released and struck him on its descent. He then lost his grip and fell backwards into the water. The alarm was raised and several life rings were thrown to the bosun's aid. Auxiliary search and rescue craft were quickly on the scene, but the bosun could not be found. His body was recovered five days later. The cause of death was drowning. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Description of the Vessel The Kent is a handy-sized bulk carrier with the wheelhouse, accommodation, and engine room located aft. The vessel has five hatches and four cranes. One 30-person lifeboat on a set of roller track gravity davits is located at each side of the accommodation. The vessel was delivered in January1985 and originally sailed as the LTOdyssey. In1998, the vessel changed ownership and was registered with the Cayman Islands, as the MillenniumOsprey. In spring2002, the vessel again changed ownership, sailing as the Kent under Hong Kong registry. The vessel remained in class with Det Norske Veritas (DNV) throughout. History of the Voyage On 30 June 2002, the Kent was in Snell lock upbound for Marinette (Wisconsin) to discharge a partial load of pig iron, when the forward cradle of the port lifeboat davit struck the lock wall and became distorted. At Marinette, the vessel was inspected by a DNV class surveyor who issued a condition of class (COC), which stated that repairs to re-align the davit were to be carried out and the system was to be operationally tested for DNV prior to the vessel transiting international waters. After discharging cargo at Marinette, the Kent continued to Thunder Bay, Ontario. On 11 July2002, the Kent departed Thunder Bay loaded with 17170metric tons of wheat. The voyage downbound through the Great Lakes and St.Lawrence Seaway was uneventful. However, the master was informed by the ship manager that stopping at a berth to repair the port lifeboat davit was to be avoided in order not to delay the voyage. On 12July, he was instructed by the operating managers to attempt a re-alignment of the davit while under way, using on-board resources at his disposal. It was suggested they use 5/10ton chain blocks anchored to welded pad eyes on deck to pull the davit into line. Additional instructions followed later requiring the use of cold repair methods only, but hot work had already been initiated. On 16 July, at around 0220,3 the Kent commenced passage through Beauharnois, Ste. Catherine and St. Lambert locks to berth at Montral at0925. That day, the port davit was surveyed by a Transport Canada (TC) inspector and a DNV surveyor who rejected the repairs as they had not been carried out in accordance with class requirements for restoration of the davit to its original state. The classification surveyor viewed the davit repairs by the crew to be temporary, considering that the efficient operation of the davit system during successive lifeboat launching/retrieval drills, or in the event of an emergency could not be relied upon. Consequently, a COC was issued by DNV in the form of a short-term flag state exemption, which stipulated that an additional 20-person liferaft be carried on the port side, until the port davit was properly repaired or renewed, but prior to 15September2002. The starboard lifeboat was lowered and raised to the satisfaction of the TC inspector and the DNV surveyor and properly secured ready for sea. Although the defective davit was not approved for safe use, the master wanted to assure himself that this equipment could be operable in the event of an emergency. Accordingly, he ordered the port lifeboat lowered and then raised to his own satisfaction. The port lifeboat had not been secured for sea. A 20-person liferaft was installed next to the port lifeboat davits in accordance with DNV requirements. At 1720, the pilot was already on board and the vessel prepared to leave Montral. The Kent was under way when the bosun was instructed to secure the port lifeboat properly for sea by connecting the fore and aft trigger lines, and he called on a seaman to help him with the work. When the seaman arrived at the port lifeboat station, the bosun was already at work. He was sitting astride the forward davit cradle, close to the underside of the lifeboat, trying to secure the forward trigger line to the trigger mechanism on the cradle (seePhoto1). The seaman climbed the aft cradle ladder and attempted to do the same with the aft trigger line. When the seaman realized there was not enough slack in the line to permit the connection, he descended the ladder with the intention of lengthening the turnbuckle at the other end. Shortly after reaching the deck he heard a noise, and turned to see the roller gravity davits with the suspended lifeboat, sliding down the cradle. Photo1. Simulation of the position of the bosun prior to being struck The noise also alerted the ship's electrician who was nearby. Both the electrician and the seaman rushed to the lifeboat davit winch and applied the brake. The lifeboat stopped descending but not before hitting the bosun, sending him backwards. He clung to the trigger line momentarily, but lost his grip and fell overboard into the water 15m below. The time was approximately1825. Man overboard was quickly communicated to the bridge where an officer of the watch, a helmsman and a pilot were navigating the vessel. The pilot immediately put the engine to dead slow ahead, but the confined area of the channel prevented a turning or full astern manoeuvre. The pilot also released the port smoke buoy, but this fell into the partially deployed port lifeboat. At approximately this time, the master arrived on the bridge and released the starboard smoke buoy. Another life ring was also thrown into the water, and persons on deck could see the bosun apparently swimming some 15to 20m from one of the buoys; however, they lost sight of him within minutes. Soon after the pilot had broadcast a PAN PAN PAN message, a yacht came out of Verchres marina and began searching the area. The crew was mustered to the boat stations and the port lifeboat was prepared, but not lowered to the water as the vessel had too much way on to launch the boat safely. As the Kent proceeded down river, reducing speed, the Canadian Coast Guard vessel CG1204 passed upbound, having joined the search. A military helicopter was also on the scene within approximately one hour of the bosun falling overboard. At 1915, the Kent came to a safe anchorage off Contrecoeur. It was still daylight and searches continued until darkness at 2130, but without success. Five days later, the bosun's body was recovered approximately 10miles downstream of the site of the incident. Victim According to the ship management company records, the victim had been sailing on various ocean-going vessels since1990. He had been a deckhand from 1990to 1994,and, since 1996,he had acted as bosun on four assignments, giving him more than three years of related experience. He held a certificate of competency as a deck rating, issued on 21November2001 by the Republic of the Philippines. His last medical exam, given at Manila on 01April2002, certified that he was in good health and fit to work. An autopsy revealed that the cause of death was drowning. Environmental Conditions The wind was calm, with clear visibility. The St.Lawrence River current was two knots setting at 045T. The water temperature was approximately 21C, and the air temperature was 22C. Vessel History and Certification Because of the change of ownership and flag in early2002, the Kent was issued short-term safety equipment and safety construction certificates by DNV at Tema, Ghana, on 02May2002. The certificates were valid until 01October2002. The certificate of registry was issued by Hong Kong Marine Department (HKMD) on 18April2002. The vessel's Minimum Safe Manning (MSM) certificate, issued at Hong Kong on 12April2002, specified six deck ratings (four seamen gradeI, one seaman gradeII, and one seaman gradeIII) and three engine-room ratings. On July12, the vessel's operating managers applied to the HKMD for a re-examination of the MSM, with the view to having the deck crew reduced from six seamen to four. The proposal was based upon a comparison of mooring arrangements and crew levels on similar ocean-going ships under management. HKMD determined a minimum deck crew of five for the Kent, and a new MSM certificate was issued on 30July2002, specifying the requirement for four seamen grade I and one seaman gradeIIorIII. The vessel held an interim International Safety Management Code (ISM) certificate, which was issued by DNVon 06May2002, and was valid to 05November2002. The managing company's Document of Compliance was issued by DNVon 04September2001. Emergency Drills Emergency fire drills and abandon ship drills were recorded in the ship's records. An overboard drill was logged on 30May2002. The lifeboats had been lowered and raised approximately four or five times since the crew had joined the vessel on 28April2002. Crew Information On 28 April2002, a new crew of 20boarded the vessel while at anchor off Tema, Ghana. The master and chief engineer were Russian nationals, and the remainder were from the Philippines. English was the common language used between the senior officers and crew. The deck department comprised the master, three officers and four seamen gradeI (bosun and three deckhands/helmsmen). Another crew member had a lower grade seaman's qualification (IIorIII), but he was assigned engine-room duties. Throughout the time the vessel was in the Great Lakes and St. Lawrence Seaway, it was operating with four deck ratings and four engine-room ratings. The bosun was on day work, and when required for special operations such as lock passage, he worked the hours necessary to accomplish the particular task. He participated in the lock operations during the vessel's downbound voyage from Thunder Bay. The ship's records indicate that on July15, the bosun was given the afternoon off prior to entering the eastern section of the Seaway, where he was required to assist in lock operations between Lake Ontario and Montral. Consequently, during the 24-hour period prior to the accident, he was off duty for approximately four hours. Port Gravity Davits Photo2. Trigger in locked position and release (inset) Each set of lifeboat gravity davits, modelST-39, complied with classification rules in force at the time of their manufacture. They were built by Sekigahara Seisakusho Ltd. of Gifu, Japan, and had been installed during vessel construction in1984. With a lifeboat on its roller gravity davits in the stowed position, the trigger line release handles are in line with the davit cradles (seePhoto2). In this locked position, the harbour pins are secured across the roller track to prevent the descent of the gravity davits holding the lifeboat. In the released position, the trigger line release handles are pulled down to the vertical, simultaneously releasing the trigger line and allowing the harbour pin to be swept aside as the gravity davits, with the suspended lifeboat, descend the davit cradle roller tracks (see inset in Photo2). The starboard lifeboat/gravity davits had been tested, safety-approved, and made ready in port for the intended voyage, with the lifeboat stowed under the gravity davits in the locked position. However, the port side davit system was in the released condition, with the lifeboat held in place with only lashing lines and the winch brake, when the vessel set sail from Montral. During the course of the accident investigation, an inspection of the port side gravity davit revealed the following: When the weighted inboard end of the brake lever mechanism was lifted into the brakeoff position, it remained stuck in the off position after the lever was released, instead of falling into place to reset the brake. With the safety pin on the brake lever mechanism in place to avoid accidental release, a gap of 12mm existed between the safety pin and the lever. This gap allowed the lever to be lifted sufficiently to disengage the brake and release the lifeboat. Parted ends of a broken lashing line showed signs of advanced corrosion and wear. Close examination by the TSB Engineering Branch established that the number of wires within the port lashing line had been reduced to 37percent of the original wire count (from144to54).4 The outboard end of the brake lever (opposite the weighted end) was extended such that the handle was near the vessel's side to control, within view, the lowering of the lifeboat down the ship's side to the waterline. The handle was in very close proximity to (6cm below and 5cm out from) the second rung of the aft cradle ladder (seePhoto3). It was further noted that if this handle was pushed down, it would have the same effect as lifting the brake lever at the inboard (weighted) end, that is, to disengage the brake. Photo3. Winch braking system (broken lashing line at upper right) Although a manufacturer's instruction manual for the davit and its equipment was found on board, the lowering and hoisting instructions were of a general nature. They did not include specific safe-working practices or details on the harbour pin and trigger line arrangements.